Republic of the Philippines )

City Of ) S.S.

AFFIDAVIT OF LOSS

I, full name, resident of address, after having been duly sworn to in accordance with law, hereby depose
and say that:

1. I am a holder/owner/ or possessor of a Certificate of Registration (COR-BIR Form 2303) issued by

the Bureau of Internal Revenue (BIR) in the year xxx;

2. Sometime in February 2019, I noticed that the aforesaid COR was missing and I could not
remember the circumstances how I lost it;

3. Despite diligent efforts to locate the same, I could no longer locate, find or recover said COR, and
to the best of my knowledge, the same can be considered lost;

4. The said COR has not been confiscated by the authorities by reason of any violation of rules and
regulations;

5. I am executing this affidavit to attest to the truth of the foregoing facts to support my application
for a new/updated Certificate of Registration.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ___________ 2019 in _____ City.

FULL NAME
Affiant
Tin No. 451-430-357-000

SUBSCRIBED AND SWORN TO BEFORE ME this ____ day of ____________ 2019 in the city of
___________________ by the affiant who exhibited to me her TIN ID with the above details.

Notary Public
Doc. No. ______;
Page No. _____;
Book No. _____;
Series of 2019.